south africa: mental health care plan

1

South Africa: Mental Health Care Plan

1. Summary Table of Mental Health Care Packages

2. Detailed description of packages.

3. Table of indicators

4. Toc map (Separate Attachment)

5. Collaborative care models for depression, alcohol misuse and schizophrenia

6. Framework for district mental health care within the re-engineered PHC service delivery platform in Dr Kenneth Kaunda District, NW

7. Table of human resource mix, services provided and tools available to assist in the provision of services

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1. Summary of MHCP packages for South Africa

ORGANISATION Engagement and mobilisation

Programme management

Capacity-building

ToCs, CAB District/sub-district management team meetings Social Cluster multisectoral forum meetings MHIS intervention

Training of trainers

FACILITY Awareness Detection, assessment & referral assessment

Drug interventions

Psychosocial interventions

Continuing care

Schizophrenia Service Providers (SP):Orientation to MHC & anti-stigma as part of PC101+ training

Collaborative care model incorporating PC101+

PC101+ PC101+ PC101+ Standard Treatment Guidelines and EDL for PHC 2008 Collaborative care model

Depression SP: Orientation to MHC & anti-stigma as part of PC101+ training

Collaborative care model incorporating PC101+

PC101+ PRIME-SA counselling intervention

Collaborative care model incorporating re-evaluation using PC101+ & appropriate referral

Alcohol SP: : Orientation to

Collaborative care model incorporating

PC101+ PC101+ Collaborative care model

3

MHC & anti-stigma as part of PC101+ training

PC101+ incorporating re-evaluation using PC101+ & appropriate referral

COMMUNITY Awareness Case detection of SMD

Rehabilitation and recovery

User mobilisation

Outreach / adherence support

Psychosis 2nd phase DoH training of CCGs

2nd phase DoH training of CCGs Training of Traditional/faith healers/other lay community counsellors

Manualized community-based PRIME-SA psychosocial rehab (PSR) groups

Recovered service users will be trained as community care worker facilitators of the PSR groups

2nd phase DoH training for CCGs

Depression 2nd phase DoH training of CCGs


Alcohol 2nd phase DoH training of CCGs


[Type text]

2. Description of Packages

1.

Organizational Packages

1.1 Engagement & Advocacy Rationale Mental Health care receives some priority but inadequate funding

and prioritisation of other diseases translates into mental health being sidelined at some levels.

Goal and objectives

Sensitise service providers about integrating mental health packages into PC101

Provider PRIME-SA and DoH

Content TOC workshop; engagement with relevant stakeholders at national, provincial and district levels (Mental Health and Substance Abuse) within department and at community level

Source TOC; Advisory Group (CAB) Indicators Input indicators:

a) Costs of meetings / human resource time(CasStu: Res) Process indicators:

b) Number of ToC workshops / CAB meetings c) Participation in meetings [ __% of staff & community members

expected to participate who do participate in ___% of meetings.] (CasStu: DocRev, ToC)

Output indicators: d) No of staff & community representativesreached through this

engagement e) No of MH specialists aware of new system

configuration/diversification of roles (CasStu: Surv) f) No of PHC providers aware of new system and inclusion of

MHC as part of their roles g) Heightened awareness of the importance of the provision of

mental health care in PHC & reduced stigma (CasSt: Qual)

Outcome indicators: h) Increase in resources available to mental health (CasStu: Surv)

[Type text]

1.2

Programme Management 1.2.1 Development & approval of MHCP Rationale It is necessary to have a district MHCP adopted by the District DoH to

ensure implementation

Goal To have the MHCP adopted by the district/sub-district management Content ToC meetings

Provider DoH& PRIME-SA Source TOC workshop; engagement with relevant stakeholders at national,

provincial and district levels (Mental Health and Substance Abuse) within department and at community level

Supervision N/A Maternal Mental Health

N/A

Indicator Input indicators: a) Costs/humanresource costs associated with development of

MHCP(CasStu: Res) Process indicators:

a) ToC meetings leading to the development of the MHCP (CasStu: DocRev)

Output indicators: a) MHCP finalised b) Operational Guidelines finalised(CasStu: DocRev)

Outcome indicators: a) MHCP approved b) Operational Guidelines approved (CasStu: DocRev) c) Evidence of resource mobilisation for sustainability /

expansion of services (CasStu: Res)

1.2.2

Ongoing District/sub-district management of the implementation of the MHCP

Goal To plan, manage, monitor and evaluate the district/sub-district mental health services in conjunction with other programmes on an on-going basis

Content Management team meetings

Provider Chronic care coordinators Mental health coordinators PHC co-ordinators District/sub-district Information officer District/sub-district pharmacist Assistant Director for Community Health Services District/sub-district managers

Source District/sub-district management team meetings District Mental Health Plan

[Type text]

Supervision N/A

Maternal Mental Health

N/A

Indicator Input indicators: a) Cost of human resource time to attend meetings/cost of new

staff(CasStu: Res) Process indicators:

a) Representation of MH on District management team b) MH regularly part of agenda of abovementioned meetings

(Case Study: Doc Rev) c) Annual ToC Review meetings held to review implementation

of the MHCP Output indicators:

a) Frequency of ToC meetings b) Review of MHCP c) Implementation of initiatives to address bottlenecks d) Deployment of specialists to train, supervise and provide a

back-up referral service(CasStu: Fac Prof) e) Creation of additional specialist posts for mental health

Outcome indicators:

1.2.3 Social Cluster meetings &multisectoral forums Goal Health to engage with other government sectors (including

Department of Social Development (DSD) and Department of Education, NGOs and NPOs) to support the integration of services for people with mental disorders.

Content Community resource mapping and mobilisation Use existing multisectoral forums to harness support and educate traditional healers, faith healers/faith healers/ police, etc

Provider Mental health coordinator Assistant Director for Community Health Services CAG (Includes representatives of Mental Health Societies (NGOs) Traditional/Faith Healers, police etc

Source Intersectoral Meetings Community Mental Health Programme CHW training manual Mental Health Care Act

Supervision N/A


N/A

Indicators Input indicators: b) Human resource costs associated with intersectoral meetings

(CasStu: Res) Process indicators:

a) No. of intersectoral meetings held b) No. of people attending these meetings

[Type text]

c) MH on meeting agenda(CasStu: DocRev) c) Attendance of these meetings by different sectors

Output indicators; a) No. of different sectors involved actively in MH care No. of lay

counsellors trained from other sectors (traditional healers/faithhealers/police)

b) No. of different sectors actively involved in mental health care Outcome indicators

a) Increase in No. of intersectoral referrals(CasStu: Res, Qual)

1.2.4 Information System Rationale Information System necessary to capture diagnosis, referral and

treatment

Goal To ensure a more comprehensive MHIS

Content Adaptation of the Mental Health Information system developed by MHaPP which distinguishes between mental health visits by adults and children under 18years; differentiates mental health visits by diagnosis; and includes treatment, counselling provided and referral.

Provider PHC personnel District Hospital Personnel Information officers

Source MHIS developed by MHaPP

Supervision N/A Maternal Mental Health

N/A

Indicators Input indicators: a) Costs / human resources for the training b) Revised MHaPP MHIS developed(CasStu: Res, FacProf,

DocRev) Process indicators:

a) No. of training sessions for PHC staff / PHC information officers in revised MHIS

b) No. / type of staff trained (CasStu:TrainFid) c) Output indicators;

a) No. of trainees with competence in new MHIS system b) MHIS data captured regularly(CasStu: TrainFid; DocRev) c) Raised awareness of need for MH information among

information officers(CasStu: TrainFid) d) Complete monthly reports on pts seen at clinic and district

hospital level for priority MNS disorders(CasStu: DocR Outcome indicators

a) Increased no. of indicators available in the MHIS(CasStu: DocRev)

b) )

[Type text]

1.2.5 Capacity Building Motivation There is a need to build capacity within the district to provide

ongoing training and supervision for task sharing interventions at the PHC Facility and Community levels of care

Goal To build capacity within the district to provide training and supervision to the PHC Facility and Community levels.

Content Training of district trainers & specialists to provide training Provision of manuals and support materials for training and supervision

Provider UCT Lung Institute PRIME SA National Department of Health

Source PC 101 PRIME counselling manuals for lay counsellors Community Mental Health Programme Manual for CHWs 1st& 2nd Phase of DoH training package for Community Caregivers Supervision guidelines

Supervision N/A


N/A

Indicators Input indicators: a) Costs and human resources to conduct ToT in training /

supervision(CasStu: Res) b) Availability of training manuals (CasStu:Surv)

Process indicators: a) No. of ToT courses run b) No. of trainers / specialists on the courses(CasStu:TrainFid)

Output indicators a) % of district trainers who are trained(CasStu:TrainFid) b) Adequacy of ToT training

Outcome indicators a) Competency of trainers to train (improved knowledge / skills

to conduct training / supportive supervision of PHC workers)(CasStu:TrainFid)

1.2.6 Supervision & support Motivation There is a need to ensure adequate clinical supervision is in place

Goal To build mechanisms to ensure supervision and support for general HCWs ongoing monitoring and evaluation of the MHCP.

Content Supervision tools Annual ToC review meetings

Provider PRIME SA National Department of Health

[Type text]

Source Supervision guidelines Supervision tools

Supervision N/A


N/A

Indicators Input indicators: a) Costs and human resources required for supervision (CasStu:

Res) b) Supervision tools (CasStu:Surv)

Process indicators: a) Supervision tools employed (CasStu:DocRev)

Output indicators a) Frequency of facility supervisions (CasStu- Fac Prof)

Outcome indicators

a) Structured supervision process in place and adequate supervision provided(CasStu: Surv; DocRev)

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2. Primary Health Facility Packages for HIV+ and ante-natal/post-natal clinic population

2.1 Awareness 2.1.1 Service provider awareness Rationale Some negative attitudes from service providers towards treating people

with mental disorders exist at PHC level as well as inadequate education about mental disorders and appropriate interventions. These need to be changed.

Goal and objective

a) To increase sensitisation about the need to provide mental health care as part of comprehensive PHC

b) To reduce stigmatizing attitudes that facility staff may have towards people with mental disorders

Provider PHC doctors PHC nurses (Includes all levels) HIV Counsellors

Content and activities (components)

Enhanced PC101 training which will include an orientation to mental health care

Source and tools

PC101 training

Training required

PC101 training – 2 days

Supervision Existing PHC Supervisory structures Mental Health Co-ordinators

Maternal mental health

Enhanced PC101 to promote awareness of maternal depression

Indicator Input indicators a) Costs/human resources for training(CasStu: Res)

Process indicators

[Type text]

a) No. of PHC nurses/MH counsellors attending PC 101 training(CasStu:TrainFid)

Output indicators a) No. of PHC workers trained/ exposed to awareness training

materials(CasStu:TrainFid) Outcome indicators

a) Change in KAB in PHC staff over time (FacSur) b) Improved provider-patient interaction/ satisfaction by service

users(CasStu:Qual)

2.1.2 Service user awareness Goal and objectives

To sensitise service users about mental health and increase demand for services

Provider Health promoters, HIV Counsellors Primary Health Care nurses

Content and activities

Exposure to educational material on waiting room TVs Pamphlets

Source and tools

South African Mental Health Federation Perinatal Mental Health Project

Training required

Supervision Mental Health Co-ordinators


Educational material on maternal depression specifically to be shown in ante-natal and post-natal waiting rooms. Source: Perinatal Mental Health Project

Indicator Input indicators a) Costs & availability of awareness-raising resources & materials

(television sets in clinics,DVDs,pamphlets)(CasStu: Res; FacSurv) Process indicators

a) No. of airings of DVDs/plays on MH in waiting rooms b) No of pamphlets / posters in health facilities

distributed(CasStu:Surv) Output indicators

a) % of health facility attendees who read/watch materials(CasStu:Surv)

b) Service user perception of accessibility and acceptability(CasStu:Surv)

Outcome indicators a) Improved MH literacy b) Improved help-seeking / increased demand for MH care from HC

attendees(CasStu:Surv; MHIS) (FacSurv)

2.2.1 Identification and diagnosis Rationale In order to provide effective interventions for persons with mental

disorders, there needs to be identification and diagnosis first.

[Type text]

Provider PHC doctor Family physician PHC nurse B. Psych counsellor/psychologist

Goal Increase identification and diagnosis of PHC service users with priority mental disorders

Content Screening and assessment for Depression, MD, AUD& Psychotic Disorders. a) Assessment whether patient needs brief interventions for alcohol

misuse or referral using stepped care referral pathways b) Referral of depression using stepped care referral pathways c) Referral of acute psychotic conditions to next level of care following

the Mental Health Care Act (2002) guidelines Source PC101

PC 101+ to include SBI (AUDIT and brief educational material on hazardous drinking) PC101+ to include refined algorythms for stepped care referral for depression for medication and/or task shifted counselling intervention PC101 includes training in the Mental Health Care Act (2002)

Supervision Family Physicians


PC101 includes assessing for maternal depression

Indicator Input indicator: a) Training materials available b) Costs/human resources for training (CasStu: FacProf)

c) Process indicator: a) No. of training sessions / Numbers attending (CasStu: TraFid)

Output indicator: a) Improved knowledge about identification /

diagnosis(CasStu:TrainFid) Outcome indicator:

a) Increased no. of people correctly identified/diagnosed with DD/AUD in the facility (FacSur)

b) Increased no. of people correctly receiving evidence-based treatment (FacSur)

2.2.2 Psychotropic medication treatment Rationale Psychotropic drugs are essential to control and treat symptoms in persons

with psychotic disorders and moderate to severe major depression Goal and objectives

Prescribing antipsychotic and anti-depressant drugs for moderate to severe mental disorders

Provider PHC doctor Psychiatrist Pharmacy assistant Pharmacist Intern

[Type text]

Professional nurse


Initiation of psychotropic medication (only medical doctors) including explanation of duration, time, side effects etc Provision of follow-up repeat medication (PHC nurses) Identification and referral of patients requiring adjustment to their medication to psychiatrist

Source and tools

Mini Drug Master Plan 2011/12-2012/13 Mini Drug Master Plan 2011/12-2013/14 Essential Drug List (EDL) Standard Treatment Guidelines and Essential Medicine List

forPrimary Health Care 2008 PC 101

Training required

PC 101

Supervision Family Physician Psychiatrist


Same procedure as above would apply

Indicator Input indicator: a) Training/human resource costs for training in PC101

b) b) Adequate stocks of medication available at PHC level (CasStu: FacProf)

c) Process indicator: a) No of nurses and PHC doctors in receipt of training(CasStu:

TrainFid) b) Regular orders of medication made to ensure adequate

stocks(CasStu: FacProf) Output indicator:

a) Improved knowledge about prescribing(CasStu: TrainFid) Outcome indicator:

a) % of patients with moderate to severe priority disorders who require medication who actually receive it(Correct dosage, frequency, duration of treatment, adherence to treatment (e.g. pill counts), loss to follow up, delivery of psychoeducation, screening for side effects, appropriateness of initiation and change of medications ins response to change in clinical status) (FacSur, Cohort)

b) Change in patient and family clinical, social and economic outcomes (Cohort) Outcomes improved and overall costs unchanged / reduced on cost-effectiveness analysis

c) Decrease in out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

2.2.3 Low intensity psychosocial support Rationale Comprehensive patient-centred PHC requires that PHC providers respond to

patients with mental health problems in a supportive manner before

[Type text]

onward referral for targeted high intensity psychosocial interventions

Goal and objectives

Provide low intensity psychosocial support to service users identified as having mental disorders during normal PHC consultation

Provider PHC nurse Content and activities (components)

Low intensity supportive counselling including psycho-education, problem solving and SBI for alcohol misuse

Source and tools

Perinatal MH Project manual for nurses/PC 101

Indicator Input indicator: a) Costs/ human resources for training (as part of PC 101

training(CasStu: Res) b) PC101 training includes low intensity supportive counselling

including psychoeducation, problem solving and SBI for alcohol misuse.

Process indicator: a) No of training sessions / No. attending(CasStu: TrainFid)

Output indicator: a) Improved skills to deliver low intensity psychosocial care(CasStu:

TrainFid) b) Outcome indicator:

a) Increased delivery of low intensity psychosocial interventions as part of routine care (FacSurv)

b) Improved patient experience of holistic care (FacSurv) 2.2.4 Targeted high intensity psychosocial/counselling

interventions Rationale Targeted high intensity psychosocial/counselling interventions for

depression co-morbid with HIV/maternal depression are required to address the large treatment gap for these disorders and to prevent the overuse of medication for these conditions, often associated with social problems, as well as promote mental health.

Provider Lay counsellors B.Psych counsellor (if available)

Goal and objectives

Provide targeted high intensity psychosocial/counselling interventions for depression/maternal depression

Content Structured manualized intervention drawing on evidence-based psychological treatments for depression (CBT/PST/IPT) delivered in groups/individually.

Source PRIME-SA lay counsellor training manual

Training required

4 day training following on from PC101 training

Supervision B.Psych counsellor (if available) Consultant intern psychologists from the sub-district hospital


Structured manualized intervention drawing on evidence-based psychological treatments for depression (CBT/PST/IPT) delivered in groups/individually delivered by lay counsellors/enrolled nurse.

[Type text]

Indicators Input indicators: a) Costs of training/human resource costs/provision for ongoing

supervision (CasStu:Res) b) Private space is available for delivery of psychosocial interventions.

(CasStu: FacProf) c) Psychosocial / counselling manual available (CasStu: FacProf)

Process indicators: a) No. of training sessions / lay counsellors who attend training

(CasStu:TraFid) b) No. of supervision sessions with lay counsellors (CasStu:FacProf) c) No. of patients referred for focused psychosocial care who accept it /

number of sessions attended / drop outs (Cohort) Output indicators:

a) No. of lay counsellors who become competent post-training(CasStu: TrainFid)

b) Increased number of service users in receipt of psychosocial intervention delivered to service users with depressive disorders and alcohol misuse for minimum duration(FacSur)

Outcome indicators: a) Change in patient and family clinical, social and economic outcomes

(Cohort) b) Outcomes improved and overall costs unchanged / reduced on cost-

effectiveness analysis Out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

2.2.5 Continuing Care Rationale People with chronic severe mental disorders (including schizophrenia,

depression and alcohol use disorders) require on-going care

Goal & Objective

To provide follow-up, case management and continuity of care to psychiatric service users

Provider PHC nurse MH Coordinator

Content & Activities

Symptom management through the provision of repeat medication & basic psycho-education and supportive counselling Trace defaulters and follow-up to re-engage treatment Assess symptoms for complications and refer patients to district/tertiary hospital for reassessment if required Refer patients to psychosocial rehabilitation groups Management/referral of co-morbid physical conditions

Source Mental Health Care Act 2002 Clinic Protocol PC 101 Standard Treatment Guidelines and Essential Medicines List for Primary Health Care 2008

Training PC 101

[Type text]

Required


If applicable

Indicators Input indicator: a) MHIS system available which includes whether psychiatric patients

are in receipt of appropriate medication as per their diagnosis (CasStu: FacSur)

b) Costs of continuing care(CasStu: Res) Process indicators;

a) Data captured on MHIS system(CasStu: FacSur) b) Mechanism for following up defaulters operational

Output indicators: a) % of defaulters who are followed up / re-engaged b) % of persons in CC who are referred to psychosocial rehab groups c) % receiving psychoeducation d) % receiving regular physical check-ups (Cohort, CasStu: HMIS,

FacProf) Outcome indicators

a) Improvement in adherence rates (MHIS system) b) Reduction in relapse rates (MHIS system) c) Improved detection of co-morbid physical health problems(Cohort,

Coh: Qual) d) Change in patient and family clinical, social and economic outcomes

(Cohort, Coh: Qual)

2.3 Collaborative Care Rationale People identified as having mental disorders by PHC nurses at the PHC

facility level need to be referred onwards within a collaborative care model for diagnosis and treatment with psychotropic medication/specialist care and/or for counselling by lay health worker counsellors.

Goal & Objective

To provide a collaborative care referral system

Provider PHC nurse PHC doctor Lay mental health counsellors Mental health specialists

Content & Activities

Based on the severity of symptoms, PHC nurses need to refer service users to the appropriate provider for further treatment. Collaborative care referral/back-referral system for priority mental disorders needs to be in operational (see item no 6 of the Mental Health Care Plan).

Source Collaborative Care Referral systems (item 6 of the MHCP)

Training Required

PC 101

Maternal Collaborative care referral system for depression

[Type text]

mental health

Indicators Input indicator: a) Explicit criteria for referral to specialist services/lay health worker

(LHW) psychosocial interventions. b) Space for LHW counsellor psychosocial interventions(CasStu:

FacProf) Process indicators; a) Referral/back-referral system operational (CasStu: FacProf) b) Data captured on a regular basis Output indicators:

a) Outcome indicators:

a) Improvement in appropriate up and down referrals(CasStu: FacProf) 2.4 Rehabilitation and Recovery: Focused psychosocial

rehabilitation Rationale Focussed psychosocial rehabilitation is essential for patients with severe

mental disorders and their families to prevent relapse and promote adherence, as well as reduce the burden of care experienced by family members/caregivers and promote recovery and social inclusion.

Provider Auxiliary social workers (DSD and Mental Health Federation) CCGs

Goal and objective

To provide psycho-education and psychosocial rehabilitation to indicated patients and families through support groups linked to clinics to reduce symptoms, disability, and family burden and improve social interaction/functioning in psychiatric service users and family members/caregivers Through community outreach, to provide psychoeducation to service users and families and follow up psychiatric service users who have relapsed and re-engage them in treatment and link them to psychosocial rehabilitation groups


Home based basic psychoeducation and supportive counselling by community caregivers (CCGs) of community outreach teams linked to clinics Psychosocial rehab groups support linked to clinics (Aux social workers)

Source and tools

2nd phase of DoH CHW training PRIME-SA Psychosocial Rehabilitation Manual (Adaptation of KZN Psychosocial Rehab Manual & Basic Needs)

Training required

DoH 2nd Phase training (CCGs) Specifically designed psychosocial rehabilitation training for the PRIME-SA Psychosocial Rehabilitation Manual developed (Aux Social workers)

Supervision Professional nurse of community outreach team (CCGs) Mental Health Coordinator/ Social worker (DSD & Mental Health Federation) (Aux Social Workers)


b) If applicable

[Type text]

Indicator Input indicator: a) SA PSR manual adapted and available (CasStd: FacProf) b) Space for PSR groups available (CasStd: FacProf) c) Cost of training (CasStd: Res)

Process indicator: a) No. of training workshops/Aux. social workers trained(CasStd:

TraFid) b) No. of psychiatric service users assessed for readiness& referred to

groups who participate (CasStd: MHIS) c) No. of groups established d) No of supervision sessions held (CasStd: FacSurv)

Output indicator: a) No. of Aux Soc Workers with competence to

run psychosocial rehabilitation groups(CasStd: TraFid) b) % of persons with severe / enduring mental disorder who participate

in rehabilitation programme for required duration(Cohort, Coh: Qual)

Outcome indicator: a) Improved clinical and functional outcomes(Cohort) b) Reduced family burden(Cohort, Coh: Qual)

c) Reduced repeat admissions(CasStu; MHIS)

3. Community Packages

3.1. Awareness Rationale Mental health literacy is low and there is little awareness or

understanding from family members and other community members about mental health issues. Consequently, communities are not aware of what constitutes mental disorders or how to deal with persons who experience mental disorders and there is stigma and discrimination of people with severe mental disorders

Goal and objectives

To sensitise the community with regard mental health and psychosocial problems

To reduce stigma towards people with mental health problems in the community

To increase demand

Provider Community Caregivers (CCGs) Health Promoters Mental Health Coordinators

Content and activities

Psychoeducation by CCGs as part of their home visits Expert talks Media campaigns and radio talk shows

Source and SA Mental Health Federation

[Type text]

tools 2nd Phase DoH training manual for CCG

Training required

First and second phase DoH training of CCGs

Supervision Professional nurse of community outreach teams Mental Health Coordinators


Promote awareness of maternal depression in above activities

Indicator Input indicators: a) Community caregiver (CCG) training material available(CasStd:

FacProf) b) Costs of developing awareness-raising material/cost of delivery of

activities (CasStu: Res) c) Process indicators:

a) No. of training sessions / No. of CCGs attending (CasStd:TraFid) b) No. of media campaigns(CasStd: FacProf)

Output indicators: Outcome indicator:

a) Increase in no of people who self-referred or were referred by community for treatment. (CasStd:MHIS)FacSurv) b) Decreased delay to help-seeking(CasStu: HMIS; FacSurv) c) Decreased discrimination / abuse (FacSurv)

3.2 Community Informant Case Detection Rationale Detection at community level will increase access to care

Goal and objective

Increase case detection in the community

Provider CCGs South African police services Auxiliary social workers Traditional healers Community lay counsellors e.g., spiritual leaders


Pro-active community case finding by trained community outreach team,South African Police Service, (auxiliary)social workers, traditional healers and lay counsellors e.g., spiritual leaders

Referral of MHCUs in need of facility (clinic or hospital) care

Source and tools

2nd Phase training manual for CCGs (Incl screening tool for AUD and depression)

Community Mental Health Programme training manual for community health workers (for traditional healers and spiritual leaders)

Training required

5 day training for traditional healers 2nd Phase DoH training of CCGs

Supervision Professional nurse of community outreach team MHCo-ordinators

[Type text]


Community outreach teams will be able to screen and refer women suspected of suffering maternal depression

Indicator Input indicator: a) Training manuals with detection protocols available(CasStu:

FacProf) b) Training costs (CasStu: Res)

Process indicator: a) No. of sessions / No. of relevant persons attending training(CasStd:

TraFid) b) No. of supervision sessions (CasStd: FacProf)

Output indicators: a) Competence to detect / refer post-training(CasStd: TraFid)

Outcome indicators: a) Increased number of detected cases / appropriate

referrals(CasStd: MHIS, FacSurv) b) Decreased delay before accessing care(CasStd: MHIS, Fac Survey)

[Type text]

[Type text]

3. INDICATOR TABLE

1. INDICATORS FOR ORGANIZATIONAL LEVEL

MHCP Function ToC Outcome

1.1 Engage, mobilise and sensitise district level stakeholders e. Health care organisation staff informed and committed to mental health programme, have reduced stigma and are willing to engage with programme

Cross-country South Africa

Input Costs of meetings / human resources (CasStu: Res) Costs of meetings / human resource time(CasStu: Res)

Process Depends on package e.g. No of meetings and participation in meetings [ __% of staff participate in ___% of meetings.] (CasStu: DocRev, ToC)

Number of ToC workshops / CAB meetings Participation in meetings [ __% of staff, categories & community members participating to participate who do participate in ___% of meetings.] (CasStu: DocRev, ToC)

Output Mental health in reports of HSO MH in approved work plan Representation of MH on HSO Level of MH activity / inclusion in work plans MH regularly (define) on agenda of HSO meetings

No. of staff & community representatives reached through this engagement No. of MH specialists aware of new system configuration/diversification of roles (CasStu: Surv) No. of PHC providers aware of new system and inclusion of MHC as part of their roles Heightened awareness of the importance of providing mental health in PHC & reduced stigma(CasStu: Qual

Outcome Heightened awareness of the importance of providing mental health in PHC and level of engagement with programme (CasStu: Qual)

)Increase in resources allocated to mental health (% increase in budget allocation for mental health) (CasStu: FacProf) Increased outreach support ) (CasStu: FacProf) % increase of human resources for mental health in line with the norms. (CasStu: FacProf)

EVALUATION

Case study may include: Qualitative: qualitative interviews (to look at awareness / stigmatising attitudes / evidence of advocacy for MH) Resources: recording of costs / programme resources Document review: documentary analysis (e.g. for monitoring what is included on agenda of meetings) ToC:ToC workshops


1.2 Programme management 1.2.1 Development & Approval of MHCP

a. MHCP approved/accepted

[Type text]


Input Costs associated with management meetings (CasStu: Res) Costs/humanresource costs associated with development of MHCP (CasStu: Res)

Process No finance meetings with MH on the agenda (CasStu: DocRev)

ToC meetings leading to the development of the MHCP (CasStu: DocRev)

Output MHCP finalised Operational Guidelines finalised Budget finalised (CasStu: DocRev) Budget sanctioned for MHCP(CasStu: Res)

MHCP finalised Operational Guidelines finalised(CasStu: DocRev)

Outcome MHCP approved Operational Guidelines approved(CasStu: DocRev) MHCP budget approved at district level (CasStu: Res) Evidence of resource mobilisation for sustainability / expansion of services compared to needs-based resource modelling tool (CasStu: Res)

MHCP approved Operational Guidelines approved(CasStu: DocRev Evidence of resource mobilisation for sustainability / expansion of services (CasStu: Res)

EVALUATION Case study may include:

Document review: review of meeting agendas and minutes, final MCHP and budget required Resources: data from HSO on budget available (not just in writing), costing tool


1.2 Programme management 1.2.2 Ongoing District/sub-district management of the implementation of the MHCP

(b) MH Programme Co-ordinator functioning adequately (c). Specialist, primary and community level service providers are in place to: 1. Train, 2. Supervise 3. Deliver services


Input Costs associated with recruiting and paying staff (CasStu: Res) Cost of human resource time to attend meetings/costs of new staff(CasStu: Res)

Process Time taken to recruit posts, unfilled posts (CasStu: DocRev)

Representation of MH on District management teamMH regularly part of agenda of above mentioned meetings (CasStu: DocRev) Annual ToC review meetings held

Output Mental health integrated into the District Health Plan. (CasStu: DocRev)

Outcome Programme co-ordinator in post [100% of programme co-ordinator function fulfilled by the start of programme roll-out] (CasStu: DocRev) MH co-ordinator functioning adequately (CasStu: Qual) No. of service providers available to provide: 1. Training, 2. Supervision, 3. Service delivery (CasStu: FacProf)

Frequency of ToC meetings to review MHCP Implementation of initiatives to address bottlenecks Creation of additional specialist posts for mental health Deployment of specialists to train, supervise and provide a back-up referral service (Outreach support for mental health training supervision and support)(CasStu: FacProf)

[Type text]

MH co-ordinator functioning adequately (CasStu: Qual) . (CasStu: FacProf)


Document review/facility survey: Data from HSO/facilities on number of personnel in post, staff turnover, successful implementation of mechanisms to ensure workers appropriately trained and supported Resources: Costing of additional human resources (WHO costing tool) Qualitative: exploration of role of co-ordinator – whether side-tracked by other issues, given sufficient time and support, effective in their post


1.2 Programme management 1.2.3 Plan and co-ordinate inter-sectoral collaboration for MHCP

d. Health care organisation staff and staff from other sectors are aware of mental illness, have reduced stigma and are willing to engage with programme


Input Costs associated with intersectoral meetings (CasStu: Res) Human resource costs associated with attending intersectoral meetings(CasStu: Res)

Process No of intersectoral meetings with MH on the agenda (CasStu: DocRev)

No. of intersectoral meetings held No. of people attending these meetings MH on meeting agenda (CasStu: DocRev) Attendance of these meetings by different sectors

Output No. of different sectors involved actively in MH care No of lay counsellors trained from other sectors (traditional healers/faithhealers/police) No. of different sectors actively involved in mental health care

Outcome Increased No. of different sectors involved actively in mental health care(CasStu: DocRev, Qual)

Increase in number of intersectoral referrals(CasStu: DocRev, Qual)


Document review: review of meeting agendas and minutes of intersectoral meetings Resources: resources allocated and costs for other sectors involved in MH care Qualitative: exploration of interaction between MH care and other sectors


1.2 Programme management e. Health information System includes key mental health indicators which are routinely

[Type text]

1.2.4 Implement a mental health information component for district health information systems

collected


Input Costs / human resources for training in MH information system (CasStu: Res)

Costs / human resources for the training Revised MHaPP MHIS developed (CasStu: Res, FacProf, DocRev)

Process No. of training sessions for PHC staff / PHC information officers in revised MHIS No. / type of staff trained (CasStu: TrainFid)

No. of training sessions for PHC staff / PHC information officers in revised MHIS No. / type of staff trained (CasStu: TrainFid)

Output No. of trainees with competence in new HMIS system (CasStu: TrainFid)

No. of trainees with competence in new HMIS system Raised awareness of need for MH information among information officers(CasStu: TrainFid) MHIS data captured regularly (CasStu: TrainFid; DocRev)

Outcome Health information system contains key mental health indicators (____,_____, ____ included in district health information system.) (CasStu: DocRev) MH indicators are collected regularly (MH indicators collected for 95% of patients) and complete monthly reports on pts seen at clinic and district hospital level for priority MNS disorders(CasStu: FacProf, DocRev)

Increased no. of indicators available in the MHIS(CasStu: DocRev) Complete monthly reports on pts seen at clinic and district hospital level for priority MNS disorders(CasStu: DocRev)

EVALUATION

Case study may include: Resources: required for running training sessions Training fidelity: pre-post training change in competence Document review: of indicators included in HMIS Facility survey: monitoring of reporting to HSO using the HMIS indicators Qualitative: exploration of collection of HMIS in facilities and use to which information system put at the HSO level. Evaluation of usefulness of indicators / ease of use / barriers to use


1.2 Programme management 1.2.5 Capacity-building HSO through training of trainers, supervisors and mentors

f. Service providers are willing and able to supervise the programme g. Service providers are able to deliver training for the intervention package


Input Costs and human resources to conduct ToT in training / supervision Costs of running supervision programme (CasStu: Res) Existence of supervision structure for MH care (CasStu: Surv)

Costs/ human resources to conduct ToT in training / supervision(CasStu: Res) Availability of training manuals(CasStu: Surv

Process No. of ToT courses run No. of trainers / specialists on the courses

No. of ToT courses run No. of trainers / specialists on the courses(CasStu: TrainFid)

[Type text]

Feedback / acceptability of training / mentoring (CasStu: TrainFid)

Output Improvement on knowledge, attitudes, skills, behaviour and stigma questionnaire score (All trained trainers and supervisors exhibit defined minimum competency in domains.) (CasStu: TrainFid)

% of district trainers who are trained(CasStu: TrainFid)

Outcome Assessment of training on checklist based on SOP for training (Trainers fulfil __% of functions on checklist) (CasStu: Surv) Assessment of supervision on checklist based on SOP for supervision (Supervisors fulfil ___% of functions on checklist) (CasStu: Surv)

Competency of trainers to train (Improved knowledge / skills to conduct training / supportive supervision of PHC workers) (CasStu: TrainFid)

EVALUATION

Case study may include: Resources: required for delivering training of trainers Training fidelity: evaluation of training of trainers – change in KAP, direct observation of training / supervising Survey: assessment of quality of training and supervision based on checklist, document review and qualitative assessment of adequacy


1.2 Programme management 1.2.6 Supervision & support

h. Adequate clinical supervision and support is in place


Input Costs and human resources required for M&E and supervision (CasStu: Res)

Costs/ human resources required for supervision & support (CasStu: Res) Supervision tools(CasStu: Surv)

Process Supervision tools employed. (CasStu: DocRev, ToC)

Output Supervision tools employed Frequency of facility supervisions Frequency of review meetings (CasStu: Surv)

Frequency of facility supervisions

Outcome M&E system for implementation of district MHCP is in place and used to feedback and improve care (CasStu: Surv) Structured supervision process in place comprising of ______,______ at all sites. (CasStu: Surv) Compliance to process measured by log book. (Supervision process in place at all sites, 90% compliance.) (CasStu: Surv)

Structured supervision process in place and adequate supervision provided (CasStu: Surv;DocRev)

EVALUATION

Case study may include: Resources: required for M&E and supervision Survey: Survey of HSO use of M&E data to improve care. Qualitative exploration of utility of the M&E mechanisms. Assessment of quality of supervision based on checklist, document review and qualitative assessment of adequacy

[Type text]

INDICATORS FOR PHC FACILITY INTERVENTION PACKAGES


2.1.1 Increase awareness of service providers to mental health problems and reduce stigma

Primary level service providers: i. Are aware of mental illness; j. have reduced stigma


Input Costs and human resources required for training (CasStu: Res) Costs/human resources for training (CasStu: Res)

Process Number of awareness raising workshops held Acceptability of training material developed (CasStu: TrainFid)

No. of PHC nurses and MH counsellors attending training (CasStu: TrainFid)

Output No. of PHC workers trained (CasStu: TrainFid) No. of PHC workers trained/exposed to awareness training materials (CasStu: TrainFid)

Outcome Change in knowledge, attitudes, behaviour score (All trained service providers exhibit defined minimum competency in domains) (CasStu: TrainFid) Number of trained PHC workers engaged in mental health care integrated into routine work (CasStu: FacProf) Change in KAB in PHC staff over time(FacSur) Improved provider-patient interaction/ satisfaction by service users (CasStu: Qual)

Change in KAB in PHC staff over time (FacSur) Improved provider-patient interaction/ satisfaction by service users (CasStu: Qual)

EVALUATION

Case study may include: Resources: required for training Training fidelity: study of knowledge / attitudes pre- and post training and also post- PRIME intervention (can look at sustainability of changes because short-term changes are often not maintained). Facility profile: retention of trained staff in MH provision, mapping what % of trained personnel are engaged actively in mental health care Qualitative: exploration of attitudes towards delivery of mental health care pre- and post PRIME Facility detection survey: Repeat KAB surveys of PHC staff in subsequent rounds of the facility detection survey.


2.1.2 Increase awareness of PHC service users to mental illness and available services **not core?

k. Service users more aware of mental illness and services available & reduced stigma l. Service user display increased demand


Input Costs and resources required for PHC awareness campaign (CasStu: Res)

Costs & availability of awareness-raising resources & materials (television sets in clinics, DVDs, pamphlets) (CasStu: Res; Facsurv)

[Type text]

Process No. of airings of DVDs on MH in waiting rooms Availability of pamphlets / posters in health facilities (CasStu: Surv)

No. of airings of DVDs on MH in waiting rooms No of pamphlets / posters in health facilities distributed (CasStu: Surv)

Output % of health facility attendees who read / watch materials % of health facility attendees who receive materials (CasStu: Surv) Service user perception of accessibility and acceptability (CasStu: Surv)

% of health facility attendees who read / watch materials (CasStu: Surv) Service users’ perception of accessibility and acceptability (CasStu: Surv)

Outcome Improved MH literacy Improved help-seeking / increased demand for MH care from PHC attendees (CasStu: Surv) (FacSurv)

Improved MH literacy Increased mental health visits Increased follow-up visits(CasStu: Surv;MHIS) (FacSurv)


Resources: required for awareness campaign Survey: study exploring implementation of PHC awareness materials – process and impact Facility detection survey: exit questionnaire include MH awareness and demand for services from PHC attendees.


2.2.1 Identification /diagnosis of priority MNS disorders m. People with mental disorders are identified and/or diagnosed in the facility


Input Procedures for identification/diagnosis in place (CasStu: FacProf)

Training materials available Costs/human resources for training(CasStu: FacProf)

Process Quality of implementation of screening procedures (CasStu: FacProf)

No. of training sessions / Numbers attending (CasStu: TrainFid)

Output No. PHC attendees identified by PHC worker as needing treatment for DD/AUD No. PHC attendees initiated treatment from DD/AUD (FacSur)

Improved knowledge about identification / diagnosis (CasStu: TrainFid)

Outcome Increased no. of people correctly identified/diagnosed with DD/AUD in the facility Sensitivity and specificity of identification/diagnosis Increased no. of people correctly receiving evidence-based treatment (FacSur)

Increased no. of people correctly identified/diagnosed with DD/AUD in the facility (FacSur) Increased no. of people correctly receiving evidence-based treatment (FacSur) Incr in % mental health case load as a proportion of total PHC headcount (CasStu: Surv;MHIS)

[Type text]


2.2.2 Prescribe and monitor psychotropic medication n. Facility based PHC personnel are able to appropriately prescribe & monitor psychotropic medication o. People with priority disorders receive appropriate psychotropic medication in the facility as intended for the required duration and are adequately referredImproved zzz. Improved health, social and economic outcomes of people living with priority mental disorders treated by the programme and their families/carers


Input Procedures for prescribing and monitoring medication available in facilities (CasStu: FacProf)

Training/human resource costs for training in PC101 Adequate stocks of medication available at PHC level (CasStu: FacProf)

Process Dosage, frequency, duration of treatment, adherence to treatment (e.g. pill counts), loss to follow up, delivery of psychoeducation, screening for side effects, appropriateness of initiation and change of medications ins response to change in clinical status (FacSur, Cohort)

No. of nurses & PHC doctors in receipt of training CasStu: TrainFid) Regular orders of medication in line with the EDL made to ensure adequate stocks (CasStu:FacSurv)

Output Appropriate quality care provided to all patients with priority disorders (FacSur, Cohort)

Improved knowledge about prescribing (CasStu: TrainFid)

Outcome Change in patient and family clinical, social and economic outcomes (Cohort) Outcomes improved and overall costs unchanged / reduced on cost-effectiveness analysis Out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

Facility based PHC personnel are able (competent and authorised)to appropriately prescribe & monitor psychotropic medication(CasStu: TrainFid) Incr in % of patients with moderate to severe priority disorders who require medication treated in line with the EDL(Cohort) Change in patient and family clinical, social and economic outcomes(Cohort) Outcomes improved and overall costs unchanged / reduced on cost-effectiveness analysis. Decrease in out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

EVALUATION

Facility detection survey: evidence-based initiation of medication in NEW cases (including necessary laboratory investigations) Cohort: changes in medication in response to clinical status / side effects including qualitative/observational study with patients / families to evaluate delivery of appropriate psychoeducation about medication. Case study may include Facility Profile which would assess the existence of procedures through document reviews, interviews and observation.

[Type text]


2.2.3 Provide low intensity psychosocial interventions p. PHC providers are able to provide low intensityc psychosocial support as part of routine care q. People with priority disorders receive low intensity psychosocial support as part of routine care


Input Private space is available for delivery of psychosocial interventions. Referral systems in place for psychosocial interventions. (CasStu: FacProf)

Costs/ human resources for training (CasStu: Res) PC101 training includes low intensity supportive counselling including psychoeducation, & problem solving and SBI for alcohol misuse. (CasStu: FacProf)

Process Dosage, frequency, duration of psychosocial interventions (Cohort,FacSur)

No. of training sessions / No. attending (CasStu: TrainFid)

Output Appropriate and quality care provided to all patients with priority disorders (FacSur, Cohort) Increased delivery of basic psychosocial interventions as part of routine care

Improved skills to deliver low intensity psychosocial care (CasStu: TrainFid)

Outcome Change in patient and family clinical, social and economic outcomes (Cohort)Improved patient experience of holistic care (Coh: Qual) Outcomes improved and overall costs unchanged / reduced on cost-effectiveness analysis Out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

Increased delivery of low intensity psychosocial interventions as part of routine care (Fac Sur) Improved patient experience of holistic care (Fac Sur)

EVALUATION

Cohort: would assess factors related to the process of medication prescription delivery and outcomes– may need observational methods / patient feedback / evaluation using case vignettes / documentary analysis of case notes where likely to be informative Facility detection survey: evidence-based initiation of psychosocial interventions in new patients Case Study may include Facility Profile would assess the existence of procedures for treatments as well as space through document reviews, interviews and observation as well

[Type text]


2.2.4 Provide high intensity targeted counselling r. Lay Health Worker counsellors are able to provide high intensity effective targeted counselling for depression in PLWHAs and maternal depression s. Lay Health Worker counsellors are able to provide high intensity effective targeted counselling for maternal depression t. People with these priority disorders receive targeted effective interventions in the facility as intended for the required duration u. People with priority disorders are adequately referred. zzz. Improved health, social and economic outcomes of people living with priority mental disorders treated by the programme and their families/carers


Input Private space is available for delivery of psychosocial interventions. (CasStu: FacProf)

Costs of training/human resource costs/provision for ongoing supervision (CasStu:Res) Private space is available for delivery of psychosocial interventions. (CasStu: FacProf) Psychosocial / counselling manual available (CasStu: FacProf)

Process Dosage, frequency, duration of psychosocial interventions (Cohort, FacSur)

No. of training sessions / lay counsellors who attend training (CasStu:TraFid) No. of supervision sessions with lay counsellors (CasStu:FacProf) No. of patients referred for focused psychosocial care who accept it / number of sessions attended / drop outs (Cohort)

Output Appropriate and quality care provided to all patients with priority disorders (FacSur, Cohort) Increased delivery of basic psychosocial interventions as part of routine care (Cohort, FacSur)

No. of lay counsellors who become competent post-training (CasStu:TraFid) Increased number of service users in receipt of psychosocial intervention delivered to service users with depressive disorders and alcohol misuse for minimum duration (CasStu:FacProf)

Outcome Improved patient experience of holistic care (Coh: Qual) Change in patient and family clinical, social and economic outcomes (Cohort) Outcomes improved and overall costs unchanged / reduced on cost-effectiveness analysis Out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

Change in patient and family clinical, social and economic outcomes (Cohort) Outcomes improved and overall costs unchanged / reduced on cost-effectiveness analysis Out-of-pocket health spending as a) % of total intervention cost, and b) % of total household income (incl. % meeting criteria for catastrophic spending). (Coh: Cost)

EVALUATION

Cohort: – may need observational methods / patient feedback / evaluation using case vignettes / documentary analysis of case notes where likely to be informative Facility detection survey: evidence-based initiation of psychosocial interventions in new patients Facility Profile: would assess the availability of space for psychosocial interventions.

[Type text]


2.2.5 Ensure continuing care through monitoring of treatment, adherence / loss to follow up and recovery in psychiatric patients with schizophrenia

t. People with chronic schizophrenia receive appropriate follow-up care. zzz. Improved health, social and economic outcomes of people living with priority mental disorders treated by the programme and their families/carers.


Input Costs of continuing care intervention (CasStu: Res) MHIS system available which includes whether psychiatric patients are in receipt of appropriate medication as per their diagnosis (CasStu: FacSur) Costs of continuing care(CasStu: Res)

Process Mechanism for following up defaulters operational CasStu: FacProf)

Data captured on HMIS system(CasStu: FacSur) Mechanism for following up defaulters operational(CasStu: FacSur)

Output % of defaulters who are followed up / re-engaged % of persons in CC who are referred appropriately for specialist input % receiving psychoeducation % receiving regular physical check-ups (Cohort, CasStu: HMIS, FacProf)

% of defaulters who are followed up / re-engaged % of persons with chronic schizophrenia who are referred to psychosocial rehab groups % receiving psycho-education % receiving regular physical check-ups (Cohort, CasStu: HMIS, FacProf)

Outcome Improvement in adherence rates Reduction in relapse rates Improved detection of co-morbid physical health problems Reduced repeat readmissions Change in patient and family clinical, social and economic outcomes (Cohort, Coh: Qual)

Improvement in adherence rates (MHIS system) Reduction in relapse rates (MHIS system) Improved detection of co-morbid physical health problems (Cohort, Coh: Qual) Change in patient and family clinical, social and economic outcomes (Cohort, Coh: Qual)

EVALUATION

Cohort to look at adherence / clinical and social outcomes Coh: Qual: Qualitative work with patients / family members in relation to quality / acceptability of care / any challenges due to outreach (increased stigma / perceived intrusiveness / coerciveness)? CasStu: FacProffor evaluation of the system for delivering continuing care .


2.3 Ensure specialist mental health care interfaces with PHC u.Collaborative care referral system to ensure a seamless service between PHC and specialist services


[Type text]

Input Programme costs Service providers who are trained are available to deliver interventions. Private space is available for delivery of psychosocial interventions. Referral systems in place for psychosocial interventions. (CasStu: FacProf)

Stepped care referral system developed for referral to specialist services/lay health worker (LHW) psychosocial interventions. Space for LHW counsellor psychosocial interventions. (CasStu: FacProf)

Process

Output Referral / back-referral consultation system operational Satisfaction from PHC and specialist MH services (CasStu: FacProf, Qual)

Referral/back-referral system operational (CasStu: FacProf) Data captured on regular basis

Outcome Seamless service across interface between PHC and specialist MH care (CasStu: FacProf)

Improvement in % of service users with appropriate up and down referrals (CasStu: FacProf)


Facility profile: surveys / qualitative exploration of specialist mental health care / PHC facilities to evaluate functioning of the interface.


2.4 Promote rehabilitation and recovery through multi-sectoral approaches and livelihood interventions

z. Interventions for people with chronic schizophrenia receive PSR (incl. livelihoods interventions, peer support, adherence support and psychosocial interventions) are linked to the clinics. People with chronic schizophrenia receive PSR (above) as intended for the required duration and are adequately referred Improved health, social and economic outcomes of people living with priority mental disorders treated by the programme and their families/carers


Input Community rehabilitation service and SOPs established in the community (CasStu: FacProf)

SA PSR manual adapted and available(CasStu: FacProf) Space for PSR groups available(CasStu: FacProf) Costs of training (CasStu: Res)

Process Community rehabilitation service functioning (CasStu: FacProf)

No. of training courses / Aux. social workers trained (CasStu; TraFid) No. of psychiatric service users assessed for readiness & referred to group who participate(CasStu; MHIS) No. of groups established No. of supervision sessions held (CasStu; FacSurv)

Output % of persons with severe / enduring mental disorder who are employed / engaged in rehabilitation programme / linked with livelihoods initiative (CasStu: FacProf, HMIS)

No. of Aux Soc Workers with competence to run psychosocial rehabilitation groups(CasStu; TraFid) % of persons with severe / enduring mental disorder who participate in rehabilitation programme for required duration (Cohort, Coh: Qual)

[Type text]

Outcome Reduced family burden Change in patient and family clinical, social and economic outcomes (Cohort, Coh: Qual)

Improved clinical and functional outcomes(Cohort) Reduced family burden(Cohort, Coh: Qual) Reduced relapse/repeat admissions(CasStu; MHIS)

EVALUATION

Cohort study of persons with psychosis / severe mental disorders Qualitative exploration with families / persons with SMD / relevant community members Case Study includes Facility profile of services, and collaboration with NGOs, CBOs

INDICATORS FOR COMMUNITY PACKAGES


3.1. Improve community awareness and decrease stigma v. Community is aware of mental illness and local availability of treatment. Stigma is reduced and demand for mental health services increased w. People with mental disorders are willing to seek treatment x. Services in the community are perceived to be accessible, affordable and acceptable to people with mental disorders so they are willing to receive intervention


Input Costs of awareness-raising activities (CasStu: Res) Community caregiver (CCG) training material available(CasStd: FacProf) Costs of developing awareness-raising material/cost of delivery of activities (CasStu: Res)

Process Depends on package(CasStd: FacProf) No. of training sessions / No. of CCGs attending (CasStd:TraFid) No. of media campaigns(CasStd: FacProf)

Output Improved knowledge, attitudes and stigma questionnaire Improved mental health literacy Decreased stigma(ComSurCoh: Qual) Reduced discrimination / abuses (ComSurCoh: Qual)

Outcome No of people who self-referred or were referred by community for treatment. (CasStu: HMIS, FacSurv)

Incr. in no of people who self-referred or were referred by community for treatment. (CasStd:MHIS)FacSurv) Decreased delay inhelp-seeking(CasStu: HMIS)FacSurv Decreased stigma/ discrimination / abuse(FacSurv)

[Type text]

EVALUATION

Community survey of mental health literacy and attitudes Case Study will include: MHIS/ facility survey: referral pathways for new patients attending Cohort: repeated measures of experiences of stigma / discrimination / abuse, Qualitative exploration of experience of living with mental illness


3.2 Improve case detection in the community y. People with mental disorders are identified in the community


Input Detection protocols in place (CasStu: FacProf) Training manuals with detection protocols available(CasStu: FacProf) Training costs (CasStu: Res)

Process No. of sessions / No. of relevant persons attending training(CasStd:TraFid) No. of supervision sessionsCasStu: FacProf)

Output No. of people identified in community by CHW (CasStu: HMIS, FacSurv)

Competence to detect / refer post-training(CasStd:TraFid)

Outcome At aggregate level, relate the total of these Ns from facilities and communities to estimated prevalence of disorders to get measure of coverage of identified and treated cases, respectively Decreased delay before accessing care (ComSur,CasStu: MHIS, Gap)

Increased number of detected cases & appropriate referrals(CasStu: HMIS, FacSurv) Decreased delay before accessing care (CasStu: HMIS, FacSurv) Incr in % follow-up care for mental health by CHWs(CasStu: HMIS, FacSurv

EVALUATION

Community Surveys – delay in seeking care pre- and post- intervention Facility surveys, HMIS - % of referrals deemed appropriate? / No. of referrals coming from the community Estimation of treatment gap: Number of detected and/or treated cases/prevalence of disorder

4. ToC Map (attachment)

[Type text]

5. Collaborative Care models

Back referral to local clinic for continued management

PHC nurse identifies depression and other mental disorders as well as other non-

communicable diseases (NCDs) using PC101. Initiates initial management of other NCDs.

Other mental disorders and NCDs including diseases of lifestyle which are inadequately controlled referred to PC

doctor/ other referral sources

If severe depression with suicide risk refer for out patient/ specialist care

9 to 10 weeks re-assessment by PHC nurse using PC101 post

the psychosocial interventions

Referral to psychosocial group

intervention sessions facilitated by lay counselors and supervised by mental

health coordinator

Referral to PC doctor for assessment & diagnosis and initiation of

psychopharmacological treatment and/ or referral to group intervention

or upward referral if suicide risk

Mild-moderate/severe depression

Severe/moderate depression

The collaborative care intervention for depression

[Type text]

[Type text]

6.Framework for district mental health care within the re-engineered PHC service delivery platform in Dr Kenneth Kaunda District, NW

Tertiary Specialist Services (Psychiatric Hospital and

Substance Abuse Treatment Centres)

Psychiatrist, Registrars, Medical Officer, Psychologist, Social Worker, Psychiatric Nurse, Occupational Therapist, Dietician, biokinetecist, pharmacist, neurologist (P/T), EEG technician , Information Officers

District/Sub-district Hospital Medical Officers, Psychologist, Psychiatrist (outreach), Registrars (outreach) Social Workers, Psychiatric nurses, Occupational Therapists, Pharmacist, Information Officers

PHC Integrated Chronic

Disease team (Psychiatrist (PT) co-opted), Family Physician, Medical Officer, Mental health coordinator (Psychiatric Nurses), Psychologist (co-opted), Social Workers; OTs, Training Officer Plus other members of ICD

Primary Health Facilities Family physician Professional nurse PHC doctors PHC Nurses Lay Counsellors Health promoters Information officer Pharmacist assistants Registered B.Psychcounsellors ?? Intern Clinical Psychologist

Community Community outreach teams (Professional nurse, enrolled nurse, CHWs/CCGs), Aux social workers, community care workers (DSD),Traditional Healers, Police, Spiritual Leaders, Private Practitioners (GPs, Psychologists & Psychiatrists), Mental health societies, other NGOs/DPOs, Teachers, MHCU groups, School health nurses

Specialised assessment& treatment EEGs Acute & long-term inpatient care Outpatient care Psychosocial rehab & psycho-education of families Downward referral to mental health coordinator & Mental Health Societies for CBR Alcohol & drug rehabilitation Outreach and support to district hospital Registrar training

Training, support & supervision of PHC personnel Programme initiation & coordination

Symptom management ( repeat medication) of chronic SMDs (PHC nurse) Brief Screening & Intervention for alcohol misuse (PHC nurse – PC 101)

Identification, support & referral of depression /maternal depression (PHC nurses – PC 101)

Manualized group psychosocial interventions for depression/maternal depression (lay counsellor)3

Diagnosis & initiation of psychotropic medication (PHC doctor/family physician) Psycho-education media campaigns in waiting rooms (HIV/general/maternal4) Collect & capture data for MHIS5

Psychosocial rehabilitation for SMDs (Aux social workers & community care workers from DSD) Identification & referral of MH problems (CHWs/CCGs)7 (Traditional healers, police, spiritual leaders)

Psycho-education media campaigns to improve MH literacy and reduce stigma & discrimination (Mental health co-ordinators/CHWs/CCGs/ MHCUs, health promoters; school health nurses )4

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Emergency admissions, 72 hr observation for involuntary patients, short-term acute inpatient care, normal in-patient care & upward referral to tertiary spec services Outpatient care Assessment & treatment of complicated cases (Psychiatrist/psychologist/medical officers) Detox Intern training Ensure sufficient stock of psychotropic medicine & package medicine, package medicine for patients, distribute to PHC facilities

[Type text]

7. Table of human resource mix, services provided and tools available to assist in the provision of services Health provider Services Tools

DISTRICT MANAGEMENT (ORGANIZATIONAL) TIER

District Management Team (MH represented by Assistant Director: Community Health Services)

Management of programmes e.g., maternal health, HAST (HIV/AIDS/STIs/TB).

Ensure collaboration with other services

District/sub-district meetings of programmes

District/sub-district PHC coordinator

Attend social cluster meetings to promote intersectoral collaboration

Collaborative meetings

Information officer Plan, manage and monitor the mental health components of the district information system.

MHIS (to be negotiated)

Provincial Indicator Data Set, DHIS

Patient Register in terms of section 39 of the Regulations to the Mental Health Care Act No 17 of 2002 for health establishments that render mental health services

District/sub-district Pharmacist

Ensuring sufficient stock of psychotropic medication

Dispensing of medication & distribution to PHC

Packaging of psychotropic medication for patients

Standard Treatment Guidelines and Essential Drug List – Hospital level Adults 2006

Standard Treatment Guidelines and Essential Medicines List for Primary Health Care 2008

District/sub-district MH coordinators

Plan, manage & monitor the district/sub-district mental health services

Attending sub-district management meetings

District/sub-district mental health care plan

Health provider Services Tools

TERTIARY HOSPITAL TIER

Psychiatrist

Assessment, diagnosis and holistic treatment (including psychiatric treatment) of in-patients/out-patients

Consultation-liaison service for PHC doctors and other mental health specialists (outreach & support)

Hospital protocol

Standard Treatment Guidelines and Essential Drug List – Hospital level Adults 2006

[Type text]

Training & supervision of registrars

Clinical Psychologist

Assessment, diagnosis and psychological treatments for in-patients and outpatients

Psycho-education of patients/families

Training of intern psychologists

Hospital protocol

Psychiatric nurse In-patient care/out-patient nursing care

Psycho-social rehabilitation

Psycho-education of families

Hospital protocol

Clinical Social Worker

Family assessment and psycho-education

Psych-education of families

Placement in alternative accommodation and/or sheltered workshops on discharge

Assist psychiatric patients with applications for disability grants

Hospital protocol

Occupational Therapist

Assessment and psycho-social rehabilitation Hospital protocol

Pharmacist Orders & dispenses medication Hospital protocol and EDL

Dietician Prepares menus Hospital protocol

Neurologist (P/T) Assesses EEGs Hospital protocol

Information officer Capture, and manage patient records District Information system

Health provider Services Tools

DISTRICT HOSPITAL TIER

Clinical Psychologist

Assessment, diagnosis and psychological treatments for in-patients (emergency admissions, 72 hr observation of involuntary patients, short-term acute inpatient care, normal in-patients & upward referral to tertiary spec services

Psychological referral service for complicated cases and more severe mental disorders

Training of intern psychologists

Support to PHC level

MH Care Act

Hospital protocol

Medical Officers Assessment, diagnosis and medical treatments for MH Care Act

[Type text]

mental disorders and other co-morbid medical conditions for in-patients/outpatients

Detox of substance abuse cases

Hospital protocol Standard Treatment Guidelines and Essential Drug List for Hospital level Adults 2006

Psychiatrist (P/T) Assessment, diagnosis and psychiatric treatment for in-patients (emergency admissions, 72 hr observation of involuntary patients, short-term acute inpatient care, normal in-patients & upward referral to tertiary spec services

Psychiatric referral service for confirmation and adjustment of diagnoses and treatment regimes for more complex psychiatric cases.

MH Care Act

Hospital protocol

Standard Treatment Guidelines and Essential Drug List for Hospital level Adults 2006

Psychiatric nurses In-patient care/out-patient nursing care

Hospital protocol

Pharmacist Ensure sufficient stock of medicine, package medicine for patients, distribute to PHC facilities

EDL

Hospital protocol

Health Provider Services Tools

PHC SPECIALIST TEAM

District/sub-district Chronic care co-ordinators (PHC Specialist team)

Training and support of PHC nurses in the emergency management and ongoing psychopharmacological treatment of psychiatric patients

Linking discharged psychiatric patients with community-based psychosocial rehab programme

Training of traditional healers, spiritual leaders, police in identification and referral of mental disorders

Media campaigns to increase mental health literacy and reduce stigma and discrimination in the clinics & community

MH Care Act & DoH training materials

Hospital protocol

Collaborative care model for schizophrenia

Existing training protocol

SAFM material

[Type text]

Psychiatrist (P/T) Psychiatric referral service for confirmation and adjustment of diagnoses and treatment regimes for more complex psychiatric cases.

Standard Treatment Guidelines and Essential Drug List for Hospital level Adults 2006

Psychologist /Intern Psychologist

Referral psychological service for patients requiring more complex psychological treatments.

Training, supervision and support for mental health coordinators & lay counsellors.

Attending district mental health management meetings

Hospital protocol

Manualized psychosocial interventions developed by PRIME-SA

Family Physician Training, supervision and support for PHC doctors and nurses in identification and management of mental disorders

PC 101+


PHC FACILITY TIER

PHC doctors Diagnosis of mental disorders & other co-morbid medical conditions

Management of comorbid medical conditions.

Initiation of psychotropic medication

Referral of mild-moderate/severe depression cases to lay counselors for the provision of manualized group/individual psychosocial interventions for depression co-morbid with chronic conditions/maternal depression

Onward referral of complex and severe cases to district outpatients services/psychiatric hospital

Brief Screening & Intervention for alcohol misuse

Emergency management and referral of patients

PC 101+

PC 101+

PC 101+

Collaborative care model using referral protocol

PC 101+, Mini Drug Master Plan 2011/12-2012/13

PC 101+ & Clinic protocol


[Type text]

with acute psychiatric conditions to the district hospital

Primary health care nurse (incl. at general, ante-natal, post-natal and chronic care)

Emergency management and transfer of acute psychiatric conditions to the district hospital

Ongoing symptom management of chronic psychiatric conditions - repeat medication

Identification of depression using PC 101 and referral

Brief Screening & Intervention for alcohol misuse (PC 101)

Record information on service users with mental disorders

Management/referral of co-morbid medical conditions

PC 101+ & Clinic protocol

Clinic protocol

PC 101+ & referral protocols using collaborative care model

PC 101+

MHIS

PC101+


B. Psych Counsellor/ PHC Psychologist/Intern Psychologist

Training and support of HIV counselors in the provision of manualized group/individual psychosocial interventions for depression

Individual counseling referral service

Manualized counselling intervention developed by PRIME-SA

HIV counselor Facilitation of manualized individual and structured group-based psychosocial interventions for depression.

Pre- and post HCT counselling

Manualized counselling intervention developed by PRIME-SA

Information officer Capture, and manage mental health components of the information system

MHIS developed by PRIME & clinic protocols

District Health Information System


COMMUNITY TIER

Community health workers

Identification & referral of people with mental disorders

Psycho-education on mental illness and stigma and discrimination

2nd Phase DoH training manual for CHWs



[Type text]

Follow-up and adherence counseling for patients who default on their medication

Mental health promotion

Conduct household visits inclusive of mental health care.

Referral of MHCUs in need of facility (clinic or hospital) care

1st Phase DoH training manual for CHWs

2nd Phase training manual for CHWs (referral document)

Social workers Assisting psychiatric patients in their applications for disability grants

Training and supervision of auxiliary social workers in the delivery of community-based psychosocial rehabilitation

DSD protocol

PSR training manual

Auxiliary social workers

Group-based psychosocial rehabilitation for MHCUs with severe chronic mental disorders

PRIME-SA psychosocial rehab manual

User Groups NGOs

Psycho-educational campaigns to improve MH literacy and reduce stigma and discriminations

Material from Federation for Mental Health

south africa: mental health care plan

Documents